APPLICATION – VellNiece Construction

1Business/Contact Information

2Specific Trade Information / Abilities / Experience

3Safety & Loss Prevention

4Financial Institution Reference

5Current Trade Reference

6Required Documentation

7Authorization & Release of Information

Business/Contact Information

Legal Business Name *

DBA (if applicable)

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone Number *

Business Fax Number

Is business ownership *

Proprietorship
Partnership
Corporation
Individual
Joint Venture
other

Years in Business *

Officers / Owners Information

Name *

Title *

Email *

Name

Title

Name (copy)

Title

Company Website Address

Is your company a minority- owned business?

If yes, what classification

Is your company a minority- owned business?

If yes, what classification

Specific Trade Information / Abilities / Experience

Type of Business / Trade *

Type(s) of Work your company is qualified to professionally provide

List the projects your company has experience completing successfully: (check all that apply)

Commercial / Mixed Use
Cultural / Community
Health Care
Industrial
Institutional / Educational
Residential
Senior Living
Other

List the projects your company has experience completing successfully: (check all that apply)

In what geographic range from your principal office are you willing to travel? *

+/ - 100 Miles
+/- 200 Miles
+/- 400 Miles
Any Areas

Indicate the size projects your company can perform *

$50K
$100K
100K - $500K
$500K - $1M
$1M - $2M
$2M - $5M
$5M - $10M
$10M

(check only one)

Has your company ever been removed or banned from a project, barred from bidding projects, or failed to complete work under contract? *

If yes, attach detailed explanation on separate sheet

Has your company ever been removed or banned from a project, barred from bidding projects, or failed to complete work under contract?

Are there any judgments, claims, arbitration proceeding, and/or legal actions pending and/or outstanding against your company, affiliates, or officers? *

If yes, attach detailed explanation on separate sheet

Are there any judgments, claims, arbitration proceeding, and/or legal actions pending and/or outstanding against your company, affiliates, or officers?

Has your company been involved in, or subject to, any legal action (or arbitration) with regard to construction contracts within the past seven (7) years? *

If yes, attach detailed explanation on separate sheet

Has your company been involved in, or subject to, any legal action (or arbitration) with regard to construction contracts within the past seven (7) years?

Safety & Loss Prevention

Please provide electronic copy of written and instituted Safety Program with accompanying policies

Completed

Please provide electronic copy of Written and instituted Safety Program with accompanying policies

Has your company in the past three (3) years been cited by FED-OSHA (or State/Commonwealth agency) for violating safety standards? *

If yes, attach copy of citation(s).

Has your company in the past three (3) years been cited by FED-OSHA (or State/Commonwealth agency) for violating safety standards?

Does your company have a drug, alcohol, and/or substance abuse policy? *

If yes, attach copy of policy.

Does your company have a drug, alcohol, and/or substance abuse policy?

Financial Institution Reference

Name

Address

Phone Number

Fax Number

Account Number

Contact Name

Current Trade Reference

(1) This reference is a *

General Contractor
Homeowner

Name *

Address *

Address Line 1

City

State

Zip Code

Phone Number *

Fax Number

Contact Name *

Contact Number *

Date Work Completed *

(2) This reference is a *

General Contractor
Homeowner

Name *

Address *

Address Line 1

City

State

Zip Code

Phone Number *

Fax Number

Contact Name *

Contact Number *

Date Work Completed *

(3) This reference is a *

General Contractor
Homeowner

Name *

Address *

Address Line 1

City

State

Zip Code

Phone Number *

Fax Number

Contact Name *

Contact Number *

Date Work Completed *

Required Documentation

(check each that is attached)

Form W-9 Request for Taxpayer Identification Number and Certification

Form W-9 Request for Taxpayer Identification Number and Certification

Form W-9 Request for Taxpayer Identification Number and Certification(upload)

Copy of Contractor's License

Copy of Contractor's License

Copy of Contractor's License(upload)

Copy of Minority Owned Business Certification Letter

Copy of Minority Owned Business Certification Letter

Copy of Minority Owned Business Certification Letter (upload)

Copy of OSHA Violation

Copy of OSHA Violation

Copy of OSHA Violation (Upload)

Copy of Safety Policy

Copy of Safety Policy

Copy of Safety Policy

Copy of Substance Abuse Policy

Copy of Substance Abuse Policy

Copy of Substance Abuse Policy (Upload)

Certificate of Insurance naming VellNiece Construction, LLC as Certificate holder

Certificate of Insurance naming VellNiece Construction, LLC as Certificate holder

Certificate of Insurance naming VellNiece Construction, LLC as Certificate holder(Upload)

Minimum Coverage Requirements:

Commercial General Liability Combined Bodily Injury and Property Damage Each Occurrence Aggregate—Per Project Aggregate—Products/Completed Operations.....$ 2,000,000.00 Automobile Liability (Including Hired and Non-Owned Liability) Combined Bodily Injury and Property Damage — Each Occurrence Workers' Compensation and Employer's Liability Employer’s Liability — Each Accident. ..$ 100,000.00 -Disease — Policy Limit ...$ 500,000.00 -Disease — Each Employee... . ... ..$ 100,000.00

Authorization & Release of Information

l, the undersigned, a principal, owner or authorized agent of the business listed below, authorize VellNiece Construction, LLC to gather any relevant performance/credit information.

Printed Legal Business Name *

Printed Name of Signatory *

Title *

Authorized Signature *

Date *

Subcontractor Prequalification Application

Business/Contact Information

Officers / Owners Information

Specific Trade Information / Abilities / Experience

Safety & Loss Prevention

Financial Institution Reference

Current Trade Reference

Required Documentation

Minimum Coverage Requirements:

Authorization & Release of Information